Provider Demographics
NPI:1225005499
Name:OLIVER, MARK ALLAN (LISW-CP, PHD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLAN
Last Name:OLIVER
Suffix:
Gender:M
Credentials:LISW-CP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11006 CHICORY FLD
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-3620
Mailing Address - Country:US
Mailing Address - Phone:719-433-8664
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP BLDG 4554
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-292-5859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC66221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical